Profiles in Patient Safety: A “Perfect Storm” in the Emergency Department

Abstract

Correct and rapid diagnosis is pivotal to the practice of emergency medicine, yet the chaotic and ill-structured emergency department environment is fertile ground for the commission of diagnostic error. Errors may result from specific error-producing conditions (EPCs) or, more frequently, from an interaction between such conditions. These EPCs are often expedient and serve to shorten the decision making process in a high-pressure environment. Recognizing that they will inevitably exist, it is important for clinicians to understand and manage their dangers. The authors present a case of delayed diagnosis resulting from the interaction of a number of EPCs that produced a ''perfect'' situation to produce a missed or delayed diagnosis. They offer practical suggestions whereby clinicians may decrease their chances of becoming victims of these influences.

Automated detection of heuristics and biases among pathologists in a computer-based system

“…Recent work has focused on categorizing these heuristics and biases (Campbell et al 2007; Croskerry 2002; Graber et al 2002), identifying contexts in which they may apply, (Dawson and Arkes 1987; Elstein 1999) and providing examples relevant to clinical medicine (Bornstein and Emler 2001; Kempainen et al 2003; Pines 2006). Many authors have suggested that reducing the use of these shortcuts may decrease biases and errors (Bornstein and Emler 2001; Croskerry 2003; Graber et al 2002).…”

Procedural pain and anxiety in paediatric patients in a Mexican emergency department

“…2011). Communication between physicians and nurses that care for the same child must be complete and effective despite the hectic emergency room environment (Campbell et al. 2007).…”

Teaching M&M rounds skills: enhancing and assessing patient safety competencies using the Ottawa M&M model

“…The survey also asked residents to enumerate five types of errors leading to adverse outcomes (as per Cosby et al ,11 table 2), three essential elements of appropriate M&M rounds cases (as per Calder et al 10) and five different types of cognitive errors (as per Campbell et al 12). …”